Complaint Investigation Report

During this investigation, the LPA interviewed the District Manager, Staff S1 through S4, and Clients C2 and C3. Interviews conducted with the Administrator and staff revealed that on 02/12/26, former staff member S5 improperly restrained Client C1. The District Manager stated that on 02/19/26, they were informed that C1 had been improperly restrained by S5. Based on agency protocol, the decision was made to place S5 on Administrative Leave pending the outcome of the investigation. Staff S1 reported that on 02/12/26, S5 inappropriately restrained C1 during a behavioral episode. According to S1, the behavior began when S5 attempted to retrieve a water bottle from C1, which C1 wanted to keep. C1 began hitting, and S1 attempted to block the strikes. At that time, S5 pushed C1 against the wall, then immediately forced C1 to the floor and sat on top of him. S1 stated that no other staff were physically involved in the incident. S1 attempted to assist, but S5 stated assistance was not needed. After some time, C1 calmed down, and S1 helped him sit up. No injuries were observed on C1. Staff S2 stated they were out of the room at the time of the incident. Upon returning, S2 observed C1 exhibiting behaviors. S2 reported that S5 instructed them to remove the other participants from the room. Although S2 did not personally witness the restraint, they were informed by S1 (make sure by whom S1 was informed) that C1 had allegedly been slammed to the floor and that S5 sat on C1’s back. Staff S3 stated they overheard employees discussing the incident and heard that S5 did not use proper CPI techniques, allegedly slammed C1 to the floor, and sat on C1’s back. Staff S4 stated that at the time of the incident, they were in a room across from where the incident occurred. S4 reported hearing raised voices and observed S5 standing in the doorway. S4 asked if assistance was needed, and S5 responded that they would handle the situation alone. The District Manager confirmed that the technique reportedly used by S5 is not permitted under CPI training guidelines. The District Manager further stated that staff have since been retrained regarding appropriate behavioral intervention techniques and proper approaches when working with clients. S5 has since resigned and is no longer employed at the facility. Clients C2 and C3 stated that they feel comfortable attending the Day Program, that staff treat them well, and that no one has restrained them. They reported no knowledge of the incident involving S5 and C1. The LPA attempted to interview C1; however, C1 is non-verbal and did not respond to the questions asked.

Based on interviews conducted and information obtained, the preponderance of evidence standard has been met, therefore, the above allegation is found to be Substantiated.

Exit interview conducted with Ka Lee. A copy of this report and Appeal Rights were provided.